Neurogenic claudication is most frequently observed in patients with degenerative lumbar spinal stenosis. We describe a patient with lumbar epidural varices secondary to obstruction of the inferior vena cava by pathological lymph nodes presenting with this syndrome. Following a diagnosis of follicular lymphoma, successful chemotherapy led to the resolution of the varices and the symptoms of neurogenic claudication. The lumbar epidural venous plexus may have an important role in the pathogenesis of spinal stenosis. Although rare, epidural venous engorgement can induce neurogenic claudication without spinal stenosis. Further investigations should be directed at identifying an underlying cause

Neurogenic myositis ossificans is a disabling condition affecting the large joints of patients with severe post-traumatic impairment of the central nervous system. It can result in ankylosis of the joint and vascular or neural compression. Surgery may be hazardous with potential haemorrhage, neurovascular injury, iatrogenic fracture and osteochondral injury. We undertook pre-operative volumetric CT assessment of 45 ankylosed hips with neurogenic myositis ossificans which required surgery. Helical CT with intravenous contrast, combined with two- and three-dimensional surface reconstructions, was the only pre-operative imaging procedure. This gave good differentiation of the heterotopic bone from the adjacent vessels. We established that early surgery, within 24 months of injury, was neither complicated by peri-operative fracture nor by the early recurrence of neurogenic myositis ossificans. Surgical delay was associated with a loss of joint space and a greater degree of bone demineralisation. Enhanced volumetric CT is an excellent method for the pre-operative assessment of neurogenic myositis ossificans and correlates well with the operative findings

Purpose: The aim of this study is to analyze objectively pathoanatomical changes of clubfoot treated with Ponseti method. Introduction: In the treatment of clubfoot, regardless of the grade and severity of the disease, first conservative treatment and serial casting should be chosen. The follow up period for surgery performed group ranges usually from 2 to 8 years (not longer than 10–15 years). Thirty years results of Ponseti’s idiopathic clubfoot treatment is with 78% success. In some recent series 95% success rate was reported. Standard conservative treatment (Kite’s) success rates are only 11% to 58% for idiopathic group. Material and Methods: Seventy patients, 115 feet (45 Bilateral, F/M 15/55) were included in the study. 28 of these patients were neurogenic group (20 Spina Bifida and 8 Artrogripotic). Since 1997, we strove Ponseti’s strict casting protocol. Bensahel’s a la carte PMR surgery was performed in 2 cases. Downey’s MRI evaluation criterias were used. In statistical analysis of the idiopathic, neurogenic and normal groups, ANOVA test was used. Results: The Navicular angle assessment was statistically significant (p< 0.05). Assessment of the results of idiopathic group was in normal range. Pathological components of Clubfoot were significantly reduced in the neurogenic group. Conclusions: Ponseti method is the effective treatment way of both the idiopathic clubfoot and the neurogenic foot. It is concluded that sound understanding of the anatomy of the foot, the biological response of young connective tissue and bone to changes in direction of mechanical stimuli, can gradually reduce or almost eliminate these deformities in most clubfeet

Purpose and background. To evaluate the clinical and cost-effectiveness of a physical and psychological group intervention (BOOST programme) compared to physiotherapy assessment and advice (best practice advice [BPA]) for older adults with neurogenic claudication (NC) which is a debilitating spinal condition. Methods and results. A randomised controlled trial of 438 participants. The primary outcome was the Oswestry Disability Index (ODI) at 12 months. Data was also collected at 6 months. Other outcomes included Swiss Spinal Stenosis Questionnaire (symptoms), ODI walking item, 6-minute walk test (6MWT) and falls. The analysis was intention-to-treat. We collected the EQ5D and health and social care use to estimate cost-effectiveness. Participants were, on average, 74.9 years old (SD 6.0). There was no significant difference in ODI scores between groups at 12 months (adjusted mean difference (MD): −1.4 [95% Confidence Intervals (CI) −4.03,1.17]), but, at 6 months, ODI scores favoured the BOOST programme (adjusted MD: −3.7 [95% CI −6.27, −1.06]). Symptoms followed a similar pattern. The BOOST programme resulted in greater improvements in walking capacity (6MWT MD 21.7m [95% CI 5.96, 37.38]) and ODI walking item (MD −0.2 [95% CI −0.45, −0.01]) and reduced falls risk (odds ratio 0.6 [95% CI 0.40, 0.98]) compared to BPA at 12 months. Probability that the BOOST programme is cost-effective ranged from 67%–89% across cost-effectiveness thresholds. Conclusions. The BOOST programme improves mobility and reduces falls in older adults with NC compared to BPA at 12 months follow-up. It is good value for the NHS. Future iterations of the programme will consider ways to reduce symptoms and disability long-term. Conflicts of interest: No conflicts of interest. Sources of funding: National Institute of Health Research – Programme for Applied Research NIHR - PTC-RP-PG-0213-20002: Better Outcomes for Older people with Spinal Trouble (BOOST). Publication and presentations: The clinical effectiveness paper has just been accepted for publication in the Journal of Gerontology Series A. The health economic analysis is not yet published. It was presented at the Physiotherapy UK conference and the International Back and Neck Pain Forum in 2021

Purpose: Claudication is a common complaint of elderly patients. Lumbar spinal stenosis (LSS) and peripheral arterial disease (PAD) are the two main etiologies, producing neurogenic and vascular claudication respectively. Physicians initially diagnose claudication based on a “typical” symptom profile. The reliability of this symptom profile to accurately diagnose LSS or PAD as a cause of claudication is unknown, leading to the potentially unnecessary utilization of expensive and overly sensitive imaging modalities. Furthermore, clinicians rely on this symptom profile when directing treatment for patients with concurrent imaging positive for LSS and PAD. This study evaluates the reliability of various symptom attributes, which classically have characterized and differentiated the two. Method: Patients presenting at a tertiary care center’s vascular or spine clinics with a primary complaint of claudication were enrolled in the study. Diagnosis of either LSS or PAD was confirmed with imaging for each patient. They answered 14 questions characterizing their symptoms. Sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR) was determined for each symptom attribute. Results: The most sensitive symptom attribute to rule out LSS is “triggering of pain with standing alone” (0.96). Four symptom attributes demonstrated a high PLR and three had low NLR for diagnosing neurogenic claudication (PLR= 3.08, 2.51, 2.14, 2.9; NLR=0.06, 0.29, 0.15). In vascular patients, calf symptoms and alleviation of pain with simply standing had a high PLR and NLR (PLR= 3.08 and 4.85; NLR= 0.31 and 0.36). Conclusion: Only four of 14 “classic” symptom attributes are highly sensitive for ruling out LSS, and should be considered by primary care physicians before pursing expensive diagnostic imaging. Six symptom attributes should be relied upon to differentiate LSS and NLR. Numbness, pain triggered with standing alone, located in the buttock and thigh, and relieved following sitting, are symptom attributes which reliably characterize neurogenic claudication

Introduction: Patients with cerebral palsy or other neurological diseases have a high incidence of foot deformities, limiting the mobility and quality of life for these patients. We analyzed the results of surgical correction and determined the optimal treatment for the main deformities. Material and Methods: We analysed retrospectively the results of surgical correction of foot deformities. 87 Patients were treated between 1995 and 2003. We have actual data from 51 Patients (59%) with 68 feet treated. Mean follow up time is 4,25 years. We had 23 Patients with neurogenic clubfoot, 16 with flatfoot, 25 with pes equinus, 2 pes cavus and 2 hallux valgus. Of these patients 73% were able to walk before surgery. Results: For the quality of life we evaluated pain, problems while walking and problems with ulcers with a Visual Analogue Scale (0–10). Pain decreased from 4,01 to 1,58 (p< 0.001), Problems with walking improved from 6,87 to 3,31 (p< 0.001), Problems with ulcers improved from 3,79 to 1,35 (p< 0.001). Maximum walking time increased from a mean of 17 minutes to 52 minutes (p< 0.001). The level of mobility was increased in 34%. These results were the basis for the analysis of the best treatment for each deformity. For each group (neurogenic clubfoot, flatfoot and equinus) the best and poorest patients were selected and analysed. What was the diagnosis, indication for surgery, mobility and expectations of the patient before the surgery compared with the outcome. Discussion: Surgical reconstruction of neurogenic foot deformities shows very good results. Essential is a muscular balancing to achieve long lasting results. Regular physiotherapy and night orthoses can improve the outcome

Purpose: Few studies have been devoted to neurogenic paraosteoarthorpathy (PAOn). We characterised the expression of genes specific for osteoblastic and chon-drocytic phenotypes using the osteomy wedge and non-mineralised tissue near the osteotome. Material and methods: Osteotomy fragments and non-mineralised tissue near the osteotomy were obtained during surgery performed in 25 patients. The explants were cultured for 56 days. We searched for the messenger RNA of the principal markers of osteoblastic, chon-drocytic, and adipocytic phenotypes, as well as certain specific proteins. Serial cryotome sections were stained for histology and immunolabelling tests. Results: Cells issuing from the osteotomy fragment and neighbouring tissues formed structures that miner-alised in culture. The following osteoblast markers were observed: alkaline phosphatase (bone isoform), osteo-calcin, Cbfa1, type 1 collagen; for chondrocytes: type II collagen, aggrecane; type X collagen as well as VEGT demonstrating the presence of hypertrophic chondrocytes.The adipocyte-specific transcription factor PPAR 2 was also found in the two cultures. The proportions and chronological expression of these markers were slightly different for the two tissues. Ex vivo study demonstrated the typical sequence of enchondral type bony formation from non-osseous cell populations. Discussion: This work provided the first characterisation of non-mineralised tissue near osteotomy. It also provided clear indications concerning the history of ectopic bone formation. The osteochondrogenic potential of connective tissue lying close to an osteotomy has not been reported previously. The persistence of this potential could explain recurrence after resection. The observation that this potential is suppressed in vivo but expressed in vitro opens a new avenue of research concerning the mechanisms controlling bone formation. Conclusion: The culture model developed in this study provides a means of studying factors determining the outcome of cell populations implicated in the formation of neurogenic paraosteoarthropathies

Hypothesis: For Neer, humeral head ascension is caused by anterior impingement. The anatomic or ischemic factors favoring anterior impingement are well known, but have not been shown to have a determining effect. Our work on the comparative action of the rotator cuff muscles to lower the humeral head (1992), led to the conclusion that the infraspinatus muscle plays a highly dominant role. The frequent association of anterior impingement and a history of cervical pain might suggest that neurogenic paresia of the infraspinatus might be involved with the impingement effect as can be observed in intermittent paresia of the lower limbs revealing a narrow lumbar canal. Since this hypothesis was put forward, we have made converging observations in a prospective study of 200 cases. Obervations:. When patients with anterior impingement were questioned, 80 were found to have a history of cervical pain which was confirmed radiographically and/or on computed tomography (CT). Physical examination of the cervical spine revealed pain at pressure on the anterolateral aspect of the C4, C5, and C6 vertebrae, always homolateral to the impingement. Search for this sign has thus become part of our routine examination and, according to Maigne, confirms the vertebral origin of peripheral pain. We found it to be absent in anterior impingements caused by trauma in young subjects, and to be inconstant in traumatic anterior impingements observed in patients aged over 55 years. After cervical arthrodesis for cervicobrachial pain, we observed five cases of progressive anterior impingement requiring decompression. In their series of 76 cervical arthrodeses for cervicobrachialgia, Hawkins et al on observed 13 cases of proven anterior impingement. They concluded there must be a relation between these two conditions. Golg et al. provided a decisive contribution to the theory when the discovered that in anterior impingement patients, rotator cuff muscles exhibit specific histological markers of muscle denervation. Conclusion: Most cases of degenerative anterior impingement result from atrophy of the rotator cuff muscles arising because of a cervical canal syndrome

Neurogenic heterotopic ossification (NHO) is a disorder of aberrant bone formation affecting one in five patients sustaining a spinal cord injury or traumatic brain injury. Ectopic bone forms around joints in characteristic patterns, causing pain and limiting movement especially around the hip and elbow. Clinical sequelae of neurogenic heterotopic ossification include urinary tract infection, pressure injuries, pneumonia and poor hygiene, making early diagnosis and treatment clinically compelling. However, diagnosis remains difficult with more investigation needed. Our pathophysiological understanding stems from mechanisms of basic bone formation enhanced by evidence of systemic influences from circulating humor factors and perhaps neurological ones. This increasing understanding guides our implementation of current prophylaxis and treatment including the use of non-steroidal anti-inflammatory drugs, bisphosphonates, radiation therapy and surgery and, importantly, should direct future, more effective ones

The neurogenic clubfoot is composed of several deformities – such as cavus and equinus, hind foot varus, supination and adduction of the forefoot – which develop due to the neurological disease leading to muscle imbalance. Whereas over-activity and spasticity occur after damage of the central nervous system, flaccid paralysis is the result of damage of the spinal motor neuron or the nerve itself. Local overload at the lateral border of the foot, poor stability and small supporting area may interfere with function and hence require treatment of the deformity. The primary aim is a functioning foot. Treatment options are conservative means or surgical procedures. Insoles are applied to correct the foot position: a lateral support forces the foot into valgus and pronation being effective only when loaded and worn in reinforced shoes. They can also be used to distribute pressure in case of local overload and sores. An individually manufactured foot orthosis provides more stability. If the forces are still overly big, the lever arm of an ankle foot orthosis is required. Surgical procedures may be carried out in addition to or instead of conservative means. Skeletal surgery should not be performed early because the neurological disease persists despite the local correction and increases the risk for recurrences. Stiffening of the foot needs to be avoided in order to preserve function. Stiffness due to cavus is reduced by a Steindler release of the plantar fascia. Equinus should not be overstressed. If necessary, it is corrected by heel cord lengthening resulting in a persistent loss of force, or by aponeurotomy maintaining force but being less efficient to gain length. To balance supination, split or complete transfer corrects the pull of hyperactive anterior or posterior tibial muscles. Lacking skeletal deformation is a prerequisite for these soft tissue procedures. Thus their presence requires bony correction alone or in addition to soft tissue surgery. The varus of the os calcis is best corrected by an original or modified Dwyer valgus osteotomy. Cavus, supination and adduction deformity can all be corrected at the midfoot. These procedures preserve mobility and hence function of the foot. Severely contracted feet, however, may need corrective fusions. Nevertheless, stiffness is badly tolerated. An alternative is application of an external fixater of the Ilizarov type to correct the skeletal deformity and followed by an additional corrective osteotomy. Botulinum toxin A paralysing a muscle for three months can be used to switch off overactive anterior or posterior tibial muscles in order to delay surgery or to prevent pull out after transfer. Application of casts to stretch overly short muscles can help to keep the deformity under control, but they need to be followed by splints in order to avoid early recurrence

We carried out the Bernese periacetabular osteotomy for the treatment of 13 dysplastic hips in 11 skeletally mature patients with an underlying neurological diagnosis. Seven hips had flaccid paralysis and six were spastic. The mean age at the time of surgery was 23 years and the mean length of follow-up was 6.4 years. Preoperatively, 11 hips had pain and two had progressive subluxation. Before operation the mean Tönnis angle was 33°, the mean centre-edge angle was −10°, and the mean extrusion index was 53%. Postoperatively, they were 8°, 25° and 15%, respectively. Pain was eliminated in 7 patients and reduced in four in those who had preoperative pain. One patient developed pain secondary to anterior impingement from excessive retroversion of the acetabulum. Four required a varus proximal femoral osteotomy at the time of the pelvic procedure and one a late varus proximal femoral osteotomy for progressive subluxation. Before operation no patient had arthritis. At the most recent follow-up one had early arthritis of the hip (Tönnis grade I) and one had advanced arthritis (Tönnis grade III). Our results suggest that the Bernese periacetabular osteotomy can be used successfully to treat neurogenic acetabular dysplasia in skeletally mature patients

Purpose: Lumbar spinal stenosis is the most common indication for spine surgery in the elderly. XStop IPD is an attractive alternative to traditional laminectomy or laminectomy with fusion as it avoids a longer procedure and anaesthesia with significantly less blood loss. The purpose of this study is to prospectively evaluate clinical outcomes, complications and functional evaluation of symptom severity, physical function and patient satisfaction following XStop IPD procedure. Method: Preoperative and postoperative clinical data as well as SF 36, visual analog scale and Roland Morris questionnaire data collected on 16 consecutive patients over 60 years undergoing XStop IPD at L3-4 and L4-5 levels or both levels. All patients had symptomatic lumbar spine stenosis with intermittent neurogenic claudication. Evaluations were made pre-operatively and post-operatively at 3, 6, 12 and 24 months. All patients had clinical radiographic data as well as data on visual analog scale SF 36 and the Roland Morris back questionnaire. Results: Patients ages ranged from 58 to 86 years with an average age of 74.25 years. In 75 percent of patients there were two or more significant co-morbidities with 18.75 percent requiring 2 level surgery. Four of the 16 patients had lumbar degenerative scoliosis with cobb angle less than 25 degrees. 50.25% the patients had grade I spondylolisthesis. No patient had previous spine surgery. In 31.25 percent of patients there was a history of diabetes. BMI ranged from 20 to 40. Seventy five percent of patients were discharged home within 24 hours. Ninety percent of patients reported relief of their leg pain at their first follow up visit within two weeks of the surgery. There were no significant complications. One-year follow up in six patients demonstrated improvements in VAS, Roland Morris criteria and SF 36 while the remaining patients have up to nine months of follow-up clinical data. Conclusion: We present our early results of this prospective study. There were significant improvements in functional outcomes. We therefore recommend the use of XStop IPD for elderly patients with multiple co-morbidities suffering from symptomatic lumbar spine stenosis with neurogenic claudication

Purpose of the study: The rate of intra and postoperative complications is generally high after surgery for neurogenic paraosteoarthropathy, also termed hetero-topic ossification. Material and methods: We present a series of 60 cases of osteoma involving the hip joint, analyzing complications in comparison with data in the literature. Results and discussion: Vascular complications (n=7): one required suture of the common femoral artery, three ligature of the deep femoral artery, two ligature of the deep femoral vein and one ligature of the collateral branches of the deep femoral vessels. Mean intraoperative blood loss was 1300 cc. None of the vascular complications gave rise to death or amputation. Early septic complications (n=4): three occurred after simple resection of the ossification and cured after surgical revision and antibiotics with no major impact on joint motion; one occurred after a procedure for resection of the ossification plus total hip arthroplasty and led to ankylosis of the hip joint but cured after surgical revision and prolonged antibiotic therapy. Sepsis was favored by a long hemorrhagic surgical procedure in patients at risk. Neurological complications (n=0): such complications are greatly feared but rare. Posterior ossifications expose the sciatic nerve to injury but generally displacement the nerve rather than enclosing it in the osteoma. Fracture complications (n=1): the outcome was favorable, both in terms of bone healing and joint motion. A classical complication mentioned in the literature and synonym to recurrent ossification or invalidating residual stiffness. Most are favored by ankylosis, osteoporosis, immobilization and a particularly dynamic surgeon. Recurrences (n=6): all were posttraumatic with a delay from accident to surgery ≥ 18 months. Conclusion: Complications are related to the localization of the osteoma (relations with nerves and vessels), associated osteopathy, and the complete or partial joint stiffness. Preoperative imaging (x-rays and computed tomography with contrast injection) should localize the osteoma, keeping in mind that certain localizations create preferential conditions for certain risks. An analysis of the topography of the paraosteoarthropathy should enable the surgeon to choose the most appropriate approach. Intraoperatively, risk assessment can usefully anticipate complications which always compromise functional outcome

Introduction: Lumbar spinal stenosis (LSS) is a condition involving the narrowing of either the spinal canal or neural foramina and may lead to intermittent neurogenic claudication (INC). Traditionally LSS is been treated by conservative therapy followed by decompression and, if required, stabilizing of the lumbar spine for non-responders. Current results indicate that decompression may lead to increase of biomechanical stresses at levels adjacent to the operated level causing degenerative disorders. In the last years dynamic devices represent an alternative for the more invasive decompression surgery. Currently a registry is maintained to collect data on patients implanted with the X STOP. Methods: Patients who were diagnosed with LSS and planned for an implantation of the X STOP were included in the study. Diagnosis was confirmed by CT or MRI scans. Outcome was measured by the Zurich Claudication Questionnaire measuring symptom severity (SS), physical function (PF), and patient satisfaction (PS). An analysis was performed for the patient who completed the pre-operative and either the 1-year follow-up or 2-year follow-up assessment. Results: 283 patients participated in the study by completing either the questionnaires by the patient or data forms by the specialist. From these 89 patients completed the pre-operative and 1-year assessment and 20 completed the pre-operative and 2-year assessment. The results showed a clinical significant change for the domains SS and PF for both 1-year follow-up and 2-year follow-up. For the domain PS the mean score is 1.81 (very satisfied = 1, somewhat satisfied = 2). The clinically significant success rate based on clinically improvement in 2 of the 3 domains is 71.9% and 65.0 % after respectively 1-year and 2-year follow-up. Discussion: Our results suggest that intermediate term clinical outcomes of X STOP IPD surgery are stable over time although it may indicate that over time a decrease in clinical significant improvement may be observed. As INC caused by LSS is an ongoing degenerative disease, this may be explained by the ongoing degenerative process

Purpose. To observe the safety and efficacy of a minimally destructive decompressive technique without fusion in patients with lumbar stenosis secondary to degenerative spondylolisthesis. Methods. 30 patients with degenerative spondylolisthesis (DS) were consecutively managed by a single consultant spinal surgeon. All patients presented with neurogenic claudication secondary to DS. All patients were managed operatively with lumbar decompression utilising an approach technique of “spinous process osteotomy” (1). Briefly, this approach requires only unilateral muscle stripping with preservation of the interspinous ligament. A standard centrolateral decompression is then performed. Data consisting of VAS back and leg pain and ODI were collected pre and post-operatively. Results. The majority of patients were women (23) with a median age of 66 years. 29 patients had grade 1 slip and 1 patient grade 2. The index level was predominantly L4/5 (25 pts; 83%) and L3/4 in the remainder (5 pts; 17%). 5 patients were noted to have a coronal plane deformity as well as DS. 3 patients underwent 2 levels of decompression. Median length of stay was 2 days (range: 1 to 13 days). 2 patients suffered a dural tear during surgery (both with scoliosis). Of these, one required a second operation to repair a pseudomeningocele. All patients improved post op (Range: 3 months to 23 months; mean 8 months). ODI significantly improved post operatively (p < 0.05). One patient, however, developed a severe recurrence of symptoms at 3 months. Repeat imaging confirmed an increased slip and recurrent stenosis. This patient underwent re-decompression supplemented with instrumented fusion. Conclusion. The technique described above facilitates a safe method of decompression alone without fusion in patients with DS, even in patients with scoliosis. The procedure is safe, successful and easy to learn. Post-operative recovery is rapid with a short hospital stay. In spite of preserving the interspinous ligament, 1/30 patients (3 %) progressed to a greater sagittal slip requiring fusion

We sought to determine the short to medium-term clinical and radiographic outcomes using a short stem in young adults with a proximal femoral deformity (PFD). We prospectively studied 31 patients (35 hips) with PFDs treated with an uncemented primary THA using a short stem with cervicometaphyseal fixation between 2011–2018. There were 19 male (23 hips) and 12 female (12 hips) patients, with a mean BMI of 26.7±4.1 kg/m. 2. Twelve cases had a previous surgical procedure, and six of them were failed childhood osteotomies. Mean age of the series was 44±12 years, mean follow-up was 81±27 months and no patients were lost to follow-up. PFDs were categorized according to a modified Berry´s classification. Average preoperative leg-length discrepancy (LLD) was −16.3 mm (−50 to 2). At a mean time of 81 months of follow-up, survival rate was 97% taking revision of the stem for any reason and 100% for aseptic loosening as endpoints. No additional femoral osteotomy was required in any case. Average surgical time was 66 minutes (45 to 100). There was a significant improvement in the mHHS score when comparing preoperative and postoperative values (47.3±10.6 vs. 92.3±3.7, p=0.0001). Postoperative LLD was in average 1 mm (−9 to 18) (p=0.0001). According to Engh's criteria, all stems were classified as stable without signs of loosening. Postoperative complications included 1 pulmonary embolism, 1 neurogenic sciatic pain, 1 transient sciatic nerve palsy that recovered completely after six months, and 2 acute periprosthetic joint infections. One patient suffered a Vancouver B2 periprosthetic femoral fracture 45 days after surgery and was revised with a modular distally fixed uncemented fluted stem. A type 2B short stem evidenced promising outcomes at short to medium-term follow up in young adult patients with PFDs, avoiding the need for corrective osteotomies and a revision stem

In spite of preventive treatment, particularly in young paraplegics with transverse lesions above T9, a high rate of neurogenic scoliosis must be expected. Due to the loss of sitting balance in the wheelchair, to increased risks of pressure sores, and to progressive restriction to the patient’s ventilatory function, surgical intervention often becomes necessary. A surgical method for successful application in SCI patients should meet specific demands:. High primary stability: External immobilisation in braces or casts would pose problems, long-lasting bed rest must be avoided and no muscular support is possible. Conversely, the instrumentation must resist against often very strong spinal spasticity. High corrective capacity in all planes: Wheelchair dependent patients have fewer facilities for compensation of a remaining spinal deformity than ambulating patients. In sub-optimal correction, the sacrum has to be included into the fusion more frequently, with serious impact on the patient’s independence in ADL. Avoidance of precedent procedures for anterior release: The ventilatory function in patients with mainly high thoracic or cervical transverse lesions is already impaired, let alone the effect of the scoliosis. Additional impacts by thoracotomy should be avoided if possible. The same aspect should also be considered, looking at the following. Posterior procedure: Because neurogenic scoliosis deformities usually need long instrumentations, exclusively anterior procedures can rarely be used. Compared with the combination of anterior (e.g. thoracic VDS) procedures together with a posterior method, a purely posterior procedure would be beneficial, as long as it can achieve equal correction. Since 1991 the author has worked on a concept using pedicle screws as cantilevers for 3-D correction, de-rotation being the core manoeuvre. The evolutive development of suitable, outrigged instruments for the reduction has now been finalised, allowing the presentation of the method. Although more than 20 cases have demonstrated the method’s superior potential in 3-D correction of the deformity, and although the primary stability provided by the method meets the requirements of this patient group, neurogenic scoliosis in para- and tetraplegics still poses inherent problems:. • Insertion of pedicle screws in scoliosis is difficult, at least in the upper thoracic region. It will take time before sufficiently accurate and available modern navigation systems can resolve this. • Once the lumbosacral junction is included in the fusion, negative impacts on the patient’s ADL, as well as on the fusion rate, must be anticipated. In conclusion, a promising and effective method for surgical correction of neurogenic scoliosis is available. The use of this method will become easier by further developments in computer assisted surgery. Having a tool at hand, which, by it’s corrective abilities, allows the sparing of the lumbosacral junction from fusion, as long as pelvic obliquity is not fixed, the detection of initial fixation by thorough follow up of the patients at risk becomes paramount

In this paper we propose a new classification of neurogenic peri-articular heterotopic ossification (HO) of the hip based on three-dimensional (3D) CT, with the aim of improving pre-operative planning for its excision. . A total of 55 patients (73 hips) with clinically significant HO after either traumatic brain or spinal cord injury were assessed by 3D-CT scanning, and the results compared with the intra-operative findings. At operation, the gross pathological anatomy of the HO as identified by 3D-CT imaging was confirmed as affecting the peri-articular hip muscles to a greater or lesser extent. We identified seven patterns of involvement: four basic (anterior, medial, posterior and lateral) and three mixed (anteromedial, posterolateral and circumferential). Excellent intra- and inter-observer agreement, with kappa values > 0.8, confirmed the reproducibility of the classification system. We describe the different surgical approaches used to excise the HO which were guided by the 3D-CT findings. Resection was always successful. . 3D-CT imaging, complemented in some cases by angiography, allows the surgeon to define the 3D anatomy of the HO accurately and to plan its surgical excision with precision. Cite this article: Bone Joint J 2015; 97-B:899–904

Perioperative pain involves both neurogenic and inflammatory mediators. The neurogenic component is produced by the intense stimulation of the surgical procedure itself. However, inflammatory mediators resulting from tissue damage and the release of certain cytokines provoke the inflammatory response. Both the neurogenic and inflammatory elements create central nervous system (CNS) excitability. While conventional pain management responds to pain as it occurs, rather than anticipating it, a more appropriate protocol may involve pre-emptive administration of analgesic medication. By beginning this administration prior to surgery and continuing it throughout the rehabilitation process, CNS pharmacological agents are utilised to achieve the following goals: 1.) decrease the neurogenic component at the wound site; 2.) depress afferent pathways; and 3.) decrease central sensitisation in the spinal column. Our experience with such pre-emptive analgesic clinical trials have included implementation of three different protocols in three groups of patients, Groups A-C. In Group A, a continuous epidural for 72-hours was utilised. A short-term epidural for 2–3 hours, followed by the use of scheduled opioid drugs and the use of anti-inflammatory medications, was used in Group B. Finally, Group C included spinal analgesia with shortacting morphine and the continued use of patient-controlled analgesia (PCA) pumps. In all groups, patients were monitored for the return of motor function, respiratory depression, ileus, pain relief, efficacy in analgesia maintenance, and cost. The following trends were observed among the variances: 1.) approximately equal length of stay in all three groups; 2.) decreased motor function in the continuous epidural group (Group A); 3.) increased ileus in the spinal group (Group C); 4.) equal pain relief in all three groups; 5.) high maintenance in the continuous epidural group (Group A); and 6.) decreased cost when continuous epidurals (Group B) were utilised. In conclusion, of the three methodologies implemented, the continuous epidural had a high failure rate (26%). While spinal analgesia is technically easier and less expensive to perform, it has a poorly defined dose response curve and is associated with an increased incidence of ileus. The scheduled opioid medications proved effective. Pre-emptive analgesia not only significantly suppresses pain, it also provides protective sensation. Our recommendation for pre-emptive pain management consists of the use of multi-modal analgesics attacking various sites along the pain pathway, including regional blocks, oral and parental opioids, topical anaesthetics, and ice. However, ongoing study is required to further delineate appropriate protocol, thorough assessment of consequences, and complications associated with all methodologies. Future protocols to be evaluated at this practice include the local injection of bupivacaine hydrochloride prior to wound closure, in addition to assessing the postoperative integration of rofecoxib into the pain management regime

Objective: The purpose of this study was to determine the safety and efficacy and evaluate several radiographic parameters after implantation of coflex™ for the primary diagnosis of spinal stenosis (1 or 2 levels) in patients with neurogenic claudication and low back pain between the ages of 40 and 80 years old. Methods: Retrospective data were gathered on 589 patients from 5 sites with 429 patients having contemporaneous clinical and radiographic follow-up. Clinical analysis was performed on 209 patients with spinal stenosis using VAS and objective examination measures to determine safety and efficacy of the coflex in relieving neurogenic claudication, radiculopathy and back pain. The median follow-up was 20 months (range 6 to 121 months) For the 209 patients, radiographic data was collected for evaluation of spinal segment motion (index and adjacent levels), implant position, migration and bony remodeling at the bone-implant interface. All device complications were recorded and independently reviewed by Medical Metrics, Inc. (Houston, TX) and an independent orthopaedic spinal surgeon (KP). Results: Moderate to severe low back pain improved in 75% of patients, while leg pain improved in 88% of patients. Claudication improved in 91% of patients and improvement in walking distance occurred in 79% of the patients. These results were achieved at 1 year and did not deteriorate over the long-term. Patient satisfaction was 88%. Complete radiographs with excellent quality were available for 180 implanted coflex devices. Sagittal rotation and translation measurements were essentially the same for all diagnoses, follow-up time points and levels of implantation. No expulsions and only 1 migration (> 5 mm) was observed. Mild and moderate bone-implant interface remodeling was noted in 15.4 %. No broken or permanently deformed implants were noted. Conclusions: coflex interspinous stabilization after microsurgical decompression for spinal stenosis demonstrates excellent short term and long term results for back pain, neurogenic claudication and patient satisfaction

Background. Neurogenic claudication is a well recognised symptom of spinal stenosis. Pain in the lower limbs and back limit walking speed and distance. Outcome of treatment should be easily measurable, but in practice is not. Walking tests are difficult to perform reliably. It is possible to measure speed and endurance with a treadmill, but this is expensive, of doubtful reliability, and many elderly patients are reasonably worried about falling off. Commonly used back pain outcome questionnaires are probably invalid for this population, and few questionnaires have been designed specifically for this complaint. The purpose of this study was to evaluate 3 questionnaires (Swiss Spinal Stenosis Score (SSS), Oxford Claudication Score (OCS) and Oswestry Disability Index (ODI)) and a Shuttle Walking Test (SWT). The Shuttle Walking Test, developed originally in respiratory medicine, shows promise as both a clinical measure and outcome measure for patients with neurogenic claudication. In an internal study, we have found that none of our patients selected for surgery can manage more than 200 metres. A fit adult can usually manage about 600 metres on this test. Study Design: Shuttle Walking Test (SWT), Swiss Spinal Stenosis Score (SSS), Oxford Claudication Score (OCS) and Oswestry Disability Index (ODI) were administered to patients with lumbar spinal stenosis (LSS) and neurogenic claudication. Objective: To determine reliability of SWT, SSS (Q1–12), OCS and ODI in LSS assessment. Methods: Thirty two clinic patients with LSS were assessed twice with one week between assessments to determine reliability. Retrospective data from 17 patients assessed before and 18 months after surgery for LSS were used to investigate use of reliability in a clinical setting. Results: Test-retest reliability was 0.92 for SWT, 0.92 for SSS, 0.83 for OCS and 0.89 for ODI (Intraclass correlation coefficient). Mean scores (percent) were SSS 51, OCS 45 and ODI 40. For 95% certainty of change between assessments for a single patient, SSS would need to change by 15, OCS by 20 and ODI by 16. Mean SWT was 150m, with change of 76m required for 95% confidence. Cronbach’s alpha was 0.91 for SSS, 0.90 for OCS and 0.89 for ODI. Change in ODI correlated most strongly with patient satisfaction after surgery (_=0.80, p< 0.001). Conclusions: Fluctuations in patient’s symptoms result in wide individual confidence intervals. Performance of SSS, OCS and ODI questionnaires are broadly similar. The condition specific SSS is most precise but not much better than the non-specific ODI. SWT gives a snapshot of physical function which is acceptable for group analysis. Use of SWT for individual assessment after surgery is feasible but multiple testing would improve sensitivity for change

Simultaneous bilateral total hip arthroplasties (THAs) present unique and unwarranted dangers to the patient and surgeon alike. These include a significantly increased risk of blood transfusion (up to 50% in contemporary series even with the use of tranexamic acid), longer operative times, longer length of stays, and higher mortality rates in patients with minimal risk factors (age > 75 years, rheumatoid arthritis, higher ASA class, and/or male sex). This is even in light of the fact that the vast majority of literature has a substantial selection bias in which only the healthiest, youngest, non-obese, and most motivated patients are included. Traditionally, simultaneous bilateral THAs were completed in the lateral decubitus position. This required the surgeon and surgical team to reposition the patient onto a fresh wound, as well as additional prepping and draping. To mitigate these additional limitations of simultaneous bilateral THAs, there has been a recent trend towards utilizing the direct anterior approach. However, this particular approach presents its own unique set of complications such as an increased risk of periprosthetic femoral fracture and early femoral failure, an increased risk of impaired wound healing (particularly in obese patients), potential injury to the lateral femoral cutaneous nerve with subsequent neurogenic pain, and traction-related neurologic injuries. When compounded with the risks of simultaneous bilateral THAs, the complication profile becomes prohibitive for an elective procedure with an otherwise very low morbidity

Heterotopic ossification (HO) is perhaps the single most significant obstacle to independence, functional mobility, and return to duty for combat-injured veterans of Operation Enduring Freedom and Operation Iraqi Freedom. Recent research into the cause(s) of HO has been driven by a markedly higher prevalence seen in these wounded warriors than encountered in previous wars or following civilian trauma. To that end, research in both civilian and military laboratories continues to shed light onto the complex mechanisms behind HO formation, including systemic and wound specific factors, cell lineage, and neurogenic inflammation. Of particular interest, non-invasive in vivo testing using Raman spectroscopy may become a feasible modality for early detection, and a wound-specific model designed to detect the early gene transcript signatures associated with HO is being tested. Through a combined effort, the goals of early detection, risk stratification, and development of novel systemic and local prophylaxis may soon be attainable.

Patients with neurogenic claudication from lumbar canal stenosis non-responsive to non-surgical treatment are usually managed with spinal decompression with or without fusion. Flexion at stenotic segments relieves symptoms by increasing canal cross-sectional area, intervertebral foraminal height. Interspinous spacers work by causing flexion at the treated segement. We used COFLEX¯ [Paradigm Spine] a titanium interspinous spacer along with interlaminar decompression where indicated. To compare the clinical and radiological results of patients undergoing interlaminar decompression with or without use of COFLEX¯. Pre and post-operative assessment and comparison of clinical outcomes of Oswestry disability index(ODI), Visual analog Scale(VAS), Short Form-36(SF-36) and radiological outcomes of disc heights of operated and adjacent levels, intervertebral foraminal heights, sagittal angles of the operated segment. All consecutive patients undergoing spinal decompression at one or more levels from Jan to Dec 2008 were included. Patients with clinically symptomatic back pain for a duration longer than claudication pain were offered interspinous spacer at L4/5 level or above. In first group(n-20), patients were treated with inter-laminar decompression and COFLEX¯ with a standard posterior approach. In second group(n-25) inter-laminar decompression for the involved segment was performed. All patients are on follow-up. Clinical and radiological outcomes were compared at 6 months and 1 year. Statistically significant(p<0.001) improvements in ODI, VAS(back), VAS(leg) and SF-36 in patients in whom COFLEX¯ was used. Radiological parameters also showed significant improvements(p<0.05). Use of COFLEX¯ spacer is justified in patients with symptomatic disc degeneration with neurogenic claudication when treated operatively

Radiological diagnosis is not the only tool in detection, monitoring of progress and making easy to undertake a decision about the surgical scoliosis correction. The below presented algorithm of scoliosis monitoring with complex and repetitive (comparative) neurophysiological examinations facilitates the doctor’s decision about method of the conservative treatment or just the moment of surgical intervention [3, 14]. Neurogenic changes in muscles can be found in early stages of the spine deformation – usually when the Cobb’s angle is over 100 [1]. Vertebral rotation and curvature progression follow simultaneously leading to deformation of the spinal cord together with the local ventral roots compression and sometimes inflammation of them. The structure of the grey matter especially in the ventral horn changes its form more on the convex side of scoliosis. Cell bodies together with the axonal hillocks in the motoneuronal pools show deformations comparing to the analogical area of the concave side. This produce discrete unilateral axonopathy in both efferent fibers of peroneal and tibial nerves in scoliotic patients at the age of about 10. This can be found in electroneurographical (ENG) recordings of M and F potentials even at the angle of scoliosis of 100 [10, 14]. Both parameters of the amplitudes and conduction velocities in M-wave studies are decreased and the frequency of F wave recording is diminished what suggests pathological asymmetrical changes just at the level of the ventral root. That is why electromyographical (EMG) recordings show asymmetrical, according to the ventral root somatotopical innervation, selective (found only in some muscles) deficits in frequency and amplitude of motor units action potentials, predominantly in girls. These girls have scoliosis accelerating the most with angle changes of 50 per year [2] that rapidly deepens the neurogenic changes. Other significant evaluation of the scoliosis acceleration is using the somatosensory evoked potentials (SEPs) for recording progression of pathology in the afferent transmission within the long ascending spinal cord pathways running in dorsal, dorsolateral and lateral funiculi [4, 5]. Changes in parameters more amplitude than conduction velocity from SEPs studies recorded at the cervical level are more visible on the concave than convex side of scoliosis. These changes are correlated with increasing the Cobb’s angle at the apical thoracic vertebrae (Th7–8) while peripheral sensory transmission remains only slightly disturbed [6, 7]. These changes were found to be twice greater when recording of SEPs was performed over cranially on the contralateral side of the scalp to the stimulation site at the ankle (tibial nerve than peroneal nerve fibers excitation) both in mothers and their daughters [4]. This points at the strong inhibition of the afferent transmission at the level of the brain stem (probably thalamus or medial lemniscus). During the comparative SEPs recordings at the cervical level, when parameters of waves change dramatically (or even they disappear), this may suggest that the lateral angle of scoliosis exceeded 450 with great acceleration of the torsion [9]. Somatosensory evoked potential recordings during the surgical correction of scoliosis showed only rarely the immediate improvement of the afferent transmission [7, 8, 11]. However, they make sure a surgeon about lack of blockade within the spinal pathways which comes from derotation and distraction procedures performed on the spine during implantation of the corrective instrumentation. First visible results of improvement in the SEPs parameters recorded postoperatively are usually seen a week after the surgery [14]. The above analogical phenomena but referring to the efferent transmission were shown in motor evoked potentials studies which were induced with the magnetic field (MEP) in areas of motor cortex and recorded from centres of cervical and lumbosacral spinal cord as well as from nerves and muscles of upper and lower extremities [12,13, 15]. Usually when AIS reaches the Cobb’s angle of 200 at the age of 25 and does not progress more it can be assumed, that its development is finished. In these patients the signs of neurogenic changes found in EMG examinations performed in lower extremities, paravertebral and gluteal muscles do not progress, too [14]

In talipes equino-varus the diminished bulk of the calf muscle suggests a neuromuscular defect. Accordingly, biopsies were taken from the postero-medial and peroneal muscle groups, and occasionally from abductor hallucis, in sixty patients mostly under the age of five years; 111 were studied histochemically and histologically, and a further fifty-three by electron-microscopy. Histochemical anomalies were revealed in ninety-two specimens; the muscle fibres in the other nineteen varied in size but were abnormal at the ultramicroscopic level, as were all specimens examined with the electron microscope. Evidence of neurogenic disease was seen in most instances and was more obvious in the older patients. The pattern of abnormality was similar in both muscle groups. It is thought that shortening of the postero-medial muscles may result from a small increase of fibrosis due to minor innervation changes occurring in intra-uterine life. There is evidence that immobilisation, stretching or relaxation of muscles does not account for the anomalies observed. This study of the extrinsic muscles in talipes equino-varus indicates a dominant neurogenic factor in its causation

Introduction & Aims: The X-stop interspinous process decompression system is being used as an alternative to laminectomy in the treatment of neurogenic claudication. To date the clinical outcomes are favourable, but the economic value has not been established within the NHS financial model. Objective: To compare the average hospital costs of performing an x-stop procedure (under general or local anaesthetic) to a laminectomy in patients with neurogenic claudication. Design: A retrospective analysis of average length of stay, anaesthetic and operative times, equipment and anaesthetic agent costs. Sources included theatre management systems, the British National Formulary and Leeds Teaching Hospitals Trust in-patient stay data. The study period was from April 2005 to October 2006. The number of patients in the two groups were 318 (laminectomy) and 75 (X-stop). Results: In comparison to laminectomy, patients under-going an X-stop procedure have a reduced average length of in-patient stay (3 versus 5 days), reduced anaesthetic time (25 versus 29 minutes) and operative duration (40 versus 128 minutes). The average cost for each procedure is £3346 for an X-stop under general anaesthetic (profit £119), £2835 for a laminectomy (profit £1177) and £2237 for an X-stop as a day case (profit £1228). Conclusions: Tariff reimbursement is an important consideration to ensure insertion of these devices is profitable for the hospital. Our results show that even with the additional cost of the implant device, an X-stop procedure under general anaesthetic remains profitable in comparison to a laminectomy, whilst a day-case X-stop procedure is more profitable. Additional savings are be made by reduced bed and theatre occupancy. Future studies will differentiate costs of 1- and 2-level X-stop procedures, complication rates and revision surgery

Objectives. Neurogenic intermittent claudication secondary to lumbar spinal stenosis is a posture dependant complaint typically affecting patients aged 50 years or older. Various treatment options exist for the management of this potentially debilitating condition. Non-surgical treatments: activity modification, exercise, NSAIDs, epidural injections. Surgical treatment options include decompression surgery and interspinous process device surgery. Interspinous process decompression is a relatively new, minimally invasive, stand-alone alternative to conservative and standard surgical decompressive treatments. The aim of this review is to evaluate the use of the X-Stop interspinous implant in all patients with spinal stenosis who were managed using the device in Northern Ireland up to June 2009. Method. We performed a retrospective review of all patients who had the X-Stop device inserted for spinal stenosis by all consultant spinal surgeons in Northern Ireland. Patient demographics, clinical symptomatology, investigative modality, post-operative quality of life, cost effectiveness, complications and long-term outcomes were assessed. Information was collected from patients using a questionnaire which was posted to them, containing the SF-36 generic questionnaire and some additional questions. Results. A total of 23 patients underwent X-stop insertion in Northern Ireland at the time of this review, 19 patients returned their questionnaires and of these 17 were completed in full and therefore included. The mean age of the study population was 60.1 years and all patients included in the study had symptoms of neurogenic claudication secondary to lumbar spinal stenosis confirmed on MRI scan. The average hospital stay was 1.5 days compared to 7.5 days for decompressive laminectomy patients. Also, at a mean follow-up of 17.8 months, 2 patients suffered direct complications of device insertion requiring removal of the implant both of these patients agreed that they would undergo the operation again in the future. SF-36 scores indicate a quality of life improvement which equates to that of other popular orthopaedic operations such as total hip and total knee replacement. X-stop insertion has been shown to be much more cost-effective than decompressive laminectomy in previous studies. Conclusion. Decompression of the lumbar spine with the X-stop interspinous implant device is safe, cost-effective, minimally invasive, and at least as effective at improving symptomatology from lumbar spinal stenosis. It is obviously more invasive than non-surgical techniques, but is less invasive than lumbar decompression procedures, is less destructive to surrounding tissues and if it fails to produce the desired results can be removed easily and the option remains for the patient to under decompression

Surgery for spondylolisthesis is controversial. It is debatable whether a spondylolisthesis should be fused in situ or reduced and fused in the corrected position. In an attempt to address this issue 68 patients who had undergone surgery between 2000 and 2005 for back and leg pain related to a spondylolisthesis with associated spinal stenosis were retrospectively reviewed. The average age was 53 years. There were 24 male and 44 female patients. A degenerative spondylolisthesis was present in 38 patients while 30 had an isthmic spondylolisthesis. All patients presented with neurogenic back and leg pain that had been present for 6 months. A major neurologic deficit was not present in any patient. The average pre-operative Oswestry score was 42%. Imaging included standard lumbar spine radiographs with dynamic views and MRI. Conservative treatment included pain medication, physiotherapy, nerve root blocks and epidural cortisone injections. A posterior in situ instrumented fusion was performed in 49 patients while 19 underwent reduction and a 360 fusion. A TLIF was used in 11 patients and an ALIF in 8. The average follow-up was 26 months. Back pain had improved in all patients and the average post-op Oswestry score was 12%. At final follow-up a radiologic fusion was present in all patients. No post-operative neurologic complication was noted in patients who had reduction of the spondylolisthesis. Leg pain persisted in 5 patients (10%) who had posterior in situ fusion while no patient who had a reduction of the spondylolisthesis had residual leg pain. These 5 patients with persistent leg pain underwent removal of the implant and an improvement was noted in 3. The authors conclude that reduction of the spondylolisthesis with an interbody fusion appears to improve the outcome with regards to neurogenic leg pain. There was no difference in the outcome for back pain

There are increasing opportunity of operative treatment for advanced aged patients with degenerative spinal disease aiming for better quality of life. We have studied such patients concerning operative result, complication and problem in pre- and peri- operative management, and achievement of their aims. Patients and Results: 1) 26 patients were analyzed; 16 males and 10 females, av. aged 82.3, pts of 19 lumbar canal stenosis with marked intermittent claudication and 7 disc herniation. 2) Low back pain and neurogenic disabilities are evaluated on JOA scoring criteria excepting ADL points (full score:15). Results: 1) 25 of 26 pts had following complications before operation; hypertension in 16, neurogenic bladder 7, arrhythmia 6, prostata hypertrophy 6, cardiac ischemic disease 4, DM 3, cerebral infarction 3, advanced OA of the knee joints 3. asthma 2, pulmonary emphysema 2, Parkinsonism 1, respectively. 2) All patients underwent laminectomy of av. 2.2 segments(1~4), and 3 pts had PL fusion. 3) One had postlaminectomy haematoma complicated with neurologic deterioration 3 hrs after operaion. He underwent immediate revision which resulted complete recovery of neurology. 4) One pt with pulmonary emphysema was operated successfully with lumbar anaesthesia as general anaesthesia was refused. 5) Improvement evaluated with modified JOA pain score accounted for as follows; av. preoperative score showed 7.16 improved to 10.73 (45.8%), objective symptoms 4.23–4.66, subjective symptome 3.0–6.08 (51.3%), ambulant ability improved from 0.35–2.0 (62.3%), and pain ± numbness of L/E 0.96–2.04 (52.9%) resp. 6) 2 patient

Aims

Patients with cauda equina syndrome (CES) require emergency imaging and surgical decompression. The severity and type of symptoms may influence the timing of imaging and surgery, and help predict the patient’s prognosis. Categories of CES attempt to group patients for management and prognostication purposes. We aimed in this study to assess the inter-rater reliability of dividing patients with CES into categories to assess whether they can be reliably applied in clinical practice and in research.

This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.

Tumours of the sacrum are difficult to manage. The sacrum provides the structural connection between the torso and lower half of the body and is subject to both axial and rotational forces. Thus, tumours or their treatment can compromise the stability of the spinopelvic junction. Additionally, nerves responsible for lower limb motor groups as well as bowel, bladder, and sexual function traverse or abut the sacrum. Preservation or sacrifice of these nerves in the treatment of sacral tumours has profound implications on the function and quality of life of the patient. This annotation will discuss current treatment protocols for sacral tumours.

Cite this article: Bone Joint J 2022;104-B(12):1284–1291.

Introduction: The existence of peripheral blood (PB) derived mesenchymal stem cells (PB-MSCs) have been documented in different mammalian species including young and adult human. However, the number of PB-MSCs is low in normal adult human blood. We have demonstrated previously that there was an increase in the number of PB-MSCs following long bone fracture and in the patients suffering from fracture non-union. The present study was to compare the biological characteristics of the PB-MSCs from fracture non-union patients, with human bone marrow derived MSCs (BM-MSCs). Methods: 200 mls PB was collected from 9 patients suffering from fracture non-union. The mononuclear cells (MNCs) were isolated by density gradients centrifugation and cultured in á-MEM containing 15% FBS. The PB-MNCs from normal donors (n=8) and BM-MSCs from patients underwent total hip replacement were used as controls. The colony forming efficiency (CFE) of the PB-MSCs was calculated, and the phenotypes of PB-MSCs and BM-MSCs were compared using immunocytochemistry and flow cytometry methods. Their multipotent differentiation potentials into osteoblasts, chondrocytes, adipocytes, neurogenic and angiogenic cells were examined under specific inductive culture media. The in vivo osteogenic potential of PB-MSCs was examined by implanting the HA-TCP blocks seeded with PB-MSCs into the SCID mice for 12 weeks. Results: After 28 days in culture, fibroblastic colonies were formed in the PB-MNCs cultures in 5 of 9 fracture non-union patients, with CFE ranging from 2.08–2.86 per 10^8 MNCs. No fibroblastic colony was seen in PB-MNCs cultures of the 8 normal donors. Under flow cytometry examination, PB-MSCs and BM-MSCs were CD34 (low) and CD105+, but PB-MSCs were CD29-, CD44-, and ALP (low), whereas BM-MSCs were CD29+, CD44+, and ALP (high). Under specific differentiation inductions, the PB-MSCs differentiated into osteoblastic cells (ALP+, type I collagen+, osteocalcin+ and Alizarin red+; chondrocytes (type II collagen+ and Alcian Blue nodules formation); adipocytes (Oil red-O positive lipid accumulation). Neurogenic differentiation was confirmed by positive neuro-filament staining, and differentiation into endothelial cells was evident with tube formation in 2D culture, and positive staining for VW factor and CD31. After implantation in the SCID mice for 12 weeks, newly formed woven bones were found in the biomaterials seeded with PB-MSCs, and they were positive for human osteocalcin immunostaining. Discussion: This study indicated that there were more PB-MSCs in the peripheral circulation of the fracture non-union patients than that in the normal subjects. This may be due to a continous systemic response for recruiting MSCs from remote bone marrow sites, with attempt to repair the fracture(s). The PB-MSCs were clearly multi-potential cells, which had shared some common phenotypic markers with BM-MSCs, as well as many distinguishable makers from the BM-MSCs. The recruitment of the PB-MSCs through circulation might be a general phenomenon of systemic responses in many pathological conditions, such as fracture or wound healing and other systemic diseases. Further understanding the roles of PB-MSCs in diseases and repair may lead to novel therapeutic strategies

Nerve growth factor (NGF) is involved in several joint diseases. It participates in pain initiation, inadequate nociception and neurogenic inflammation; its concentrations are increased in synovial fluid and tissue from human and experimental arthritis. However, data about its role in normal and pathological articular cartilage are scant and conflicting. This study assesses the effects of different. NGF concentrations on cultured healthy human chondrocytes by evaluating cell proliferation, cell phenotype, and gene expression. The 3-[4,5-dimethylthiazol-2-y1]-2,5-diphenyl-2H-tetrazolium bromide (MTT) test excluded an influence on cell viability; alcian blue and S100 staining demonstrated that NGF induced de-differentiation of the chondrocyte phenotype; real-time PCR disclosed that it reduced the expression of collagen type II (COL2A1) and transforming growth factor-β (TGF-β), key factors involved in articular cartilage integrity, and stimulated upregulation of metalloproteinase (MMP)-3 and MMP-13. These findings suggest that NGF may adversely affect differentiated chondrocytes from articular cartilage by inhibiting the expression of the collagens found in normal articular cartilage (COL2A1), while exerting a degradative effect though TGF-β downregulation and MMP-13 and MMP-3 upregulation. Further investigation is required to determine whether the gene expression pattern found in our study is associated with changes in protein expression

Aims

Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs.

Aims

Traumatic central cord syndrome (CCS) typically follows a hyperextension injury and results in motor impairment affecting the upper limbs more than the lower, with occasional sensory impairment and urinary retention. Current evidence on mortality and long-term outcomes is limited. The primary aim of this study was to assess the five-year mortality of CCS, and to determine any difference in mortality between management groups or age.

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Cite this article: Bone Joint J 2023;105-B(4):347–355.

The August 2023 Spine Roundup360 looks at: Changes in paraspinal muscles correspond to the severity of degeneration in patients with lumbar stenosis; Steroid injections are not effective in the prevention of surgery for degenerative cervical myelopathy; A higher screw density is associated with fewer mechanical complications after surgery for adult spinal deformity; Methylprednisolone following minimally invasive lumbar decompression: a large prospective single-institution study; Occupancy rate of pedicle screw below 80% is a risk factor for upper instrumented vertebral fracture following adult spinal deformity surgery; Deterioration after surgery for degenerative cervical myelopathy: an observational study from the Canadian Spine Outcomes and Research Network.

Study design. Prospective randomized study. Objective. Primary aim of this study was to compare clinical and radiological results of transforaminal lumbar interbody fusion (TLIF) with posterolateral (interlaminar) instrumented lumbar fusion (PLF) in adult low grade (Meyerding 1 & 2) spondylolisthesis patients. Background data. Theoretically, TLIF has better radiological result than PLF in spondylolisthesis in most of the studies. Method. 24 patients of low grade adult spondylolisthesis were randomly allocated to one of the two groups: group 1- PLF and group 2-TLIF. Study period was between August 2010 to March 2013. All patients were operated by a single surgeon (CN). Posterior decompression was performed in all patients. Average follow up period was 18.4 months. Quality of life was accessed with Visual analogue scale and Oswestry Low Back Pain Disability Index. Fusion was assessed radiologically by CT scan and X-ray. Result. Though fusion was significantly better in TLIF group, clinical outcome including relief of back pain and neurogenic claudication were better in PLF group. Rate of complication was also lower in PLF group. Conclusion. Considering the low complication rate and similar or better clinical results, posterolateral instrumented lumbar fusion is the better option in low grade adult spondylolisthesis

The August 2023 Wrist & Hand Roundup360 looks at: Complications and patient-reported outcomes after trapeziectomy with a Weilby sling: a cohort study; Swelling, stiffness, and dysfunction following proximal interphalangeal joint sprains; Utility of preoperative MRI for assessing proximal fragment vascularity in scaphoid nonunion; Complications and outcomes of operative treatment for acute perilunate injuries: a systematic review; The position of the median nerve in relation to the palmaris longus tendon at the wrist: a study of 784 MR images; Basal fractures of the ulnar styloid? A randomized controlled trial; Proximal row carpectomy versus four-corner arthrodesis in SLAC and SNAC wrist; Managing cold intolerance after hand injury: a systematic review.

The diagnostic sub-categorization of cauda equina syndrome (CES) is used to aid communication between doctors and other healthcare professionals. It is also used to determine the need for, and urgency of, MRI and surgery in these patients. A recent paper by Hoeritzauer et al (2023) in this journal examined the interobserver reliability of the widely accepted subcategories in 100 patients with cauda equina syndrome. They found that there is no useful interobserver agreement for the subcategories, even for experienced spinal surgeons. This observation is supported by the largest prospective study of the treatment of cauda equina syndrome in the UK by Woodfield et al (2023). If the accepted subcategories are unreliable, they cannot be used in the way that they are currently, and they should be revised or abandoned. This paper presents a reassessment of the diagnostic and prognostic subcategories of cauda equina syndrome in the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization.

Cite this article: Bone Joint J 2024;106-B(3):227–231.

Aims

Lumbar spinal stenosis (LSS) is a common skeletal system disease that has been partly attributed to genetic variation. However, the correlation between genetic variation and pathological changes in LSS is insufficient, and it is difficult to provide a reference for the early diagnosis and treatment of the disease.

Aims

To identify the incidence and risk factors for five-year same-site recurrent disc herniation (sRDH) after primary single-level lumbar discectomy. Secondary outcome was the incidence and risk factors for five-year sRDH reoperation.

Aims

The aim of this meta-analysis was to determine the pooled incidence of postoperative urinary retention (POUR) following total hip and knee arthroplasty (total joint replacement (TJR)) and to evaluate the risk factors and complications associated with POUR.

Aims

Cauda equina syndrome (CES) can be associated with chronic severe lower back pain and long-term autonomic dysfunction. This study assesses the recently defined core outcome set for CES in a cohort of patients using validated questionnaires.

A three-month-old girl presented with a massive abdominal tumour arising from the right lumbar region. Microscopic examination of a biopsy specimen showed a typical neuroblastoma. No treatment was given except that necessary symptomatically for paralysis caused by compression of the cauda equina. Spontaneous regression was accompanied by maturation to a small ganglioneuroma, found at necropsy examination at the age of ten years. Death was from urinary infection due to a persistent neurogenic bladder